Coronal fracture of teeth is a prevalent form of dental trauma. Mainly it affects anterior teeth due to accidental injury, but sometimes posterior teeth may also get affected. The immediate restoration of the original fractured segment not only offers an alternative treatment in the emergency but also restores patien

Bains, Rhythm

Singh, Meena

Tikku, Aseem Prakash

Verma, Promila

English

Atharva Scientific Publications (E-Jounals)

Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 87
Case Series
Management of complicated crown fracture by reattachment with super 
bond: A case series
Promila Verma, Rhythm Bains, Aseem Prakash Tikku, Meena Singh
From Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, King George Medical University, Lucknow, Uttar Pradesh, 
India
Correspondence to: Dr. Promila Verma, Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, King 
George Medical University, Lucknow, Uttar Pradesh, India. E-mail: promilarajesh@yahoo.co.in
Received - 17 March 2018 Initial Review - 14 April 2018 Published Online - 12 May 2018
Dental injury in the form of coronal fracture is very commonly encountered and affects deciduous as well as permanent dentition. Coronal fracture has been 
reported to be as much as 92% of all the traumatic injuries of the 
permanent dentition [1]. In general, such type of injuries involves 
anterior teeth, especially maxillary incisors due to its position 
in arch making it more prone to traumatic injuries. However, 
sometimes, impact of trauma also causes fractures of maxillary or 
mandibular posterior teeth [2]. Ideally, a dental restoration should 
be as strong and natural as tooth structure. Therefore, in many 
clinical situations, reattachment of the fractured fragment restores 
the original tooth surface texture, contour, color, appearance, and 
shape of tooth [3]. Apart from the advantages above, reattachment 
provides a minimum sacrifice of the remaining tooth structure 
being less time consuming with more successful long-term 
results [4].
Management of the crown root fracture is also very 
challenging if periodontal ligament is involved, as access and 
isolation of fractured margin for restoration are difficult [5]. 
Variety of the treatment options is available for the management 
of the complicated crown-root fracture. The success of the 
reattachment depends on the several factors such as size 
of the fragment, periodontal involvement, biological width 
violation, duration of the fracture and contamination of the 
site, and material used for the reattachment [6]. Clinicians have 
used various techniques and materials to reattach fractured 
fragment of tooth, and the most common technique is to use 
a flowable composite resin. The problem associated with the 
use of composite resin is strict maintenance of isolation, which 
becomes difficult and sometimes impossible when the fractured 
margin is subgingivally located.
Super bond (Sun Medical, Japan) is a newly introduced self-
curing dental adhesive resin cement material based on acrylic 
resin technology. Manufacturers claim excellent bond strength to 
tooth structure (enamel and dentin), metal, porcelain, and dental 
resins with pulpal safety due to the formation of a hybrid layer 
(resin impregnated layer) in both enamel and dentin. This layer 
reinforces the tooth surface against recurrent caries and prevents 
the post-operative hypersensitivity. We report the treatment 
of three coronal fractures at various levels using this adhesive 
material, Super bond.
CASE REPORTS
Case 1
A 26-year-old male patient reported to the dental outpatient 
department, with the chief complaint of fractured maxillary 
central incisor due to fall on the ground a week ago. Intraoral 
examination showed Ellis Class III fracture in the right maxillary 
central incisor. The fractured fragment was mobile, and fracture 
line extended subgingivally up to 2 mm. Radiographic examination 
revealed oblique fracture running from mesioincisal angle of the 
crown to distocervical portion and extending subgingivally on the 
root. Any additional root fracture was ruled out. After a thorough 
examination, all treatment options were explained to the patients. 
ABSTRACT
Coronal fracture of teeth is a prevalent form of dental trauma. Mainly it affects anterior teeth due to accidental injury, but sometimes 
posterior teeth may also get affected. The immediate restoration of the original fractured segment not only offers an alternative 
treatment in the emergency but also restores patient’s emotional and functional problem. Reattachment of the fractured fragment, 
if it is available can provide excellent and long-lasting esthetics because it maintains tooth original contour, anatomy, and surface 
texture. If fracture line is subgingival, then one of the main problems during reattachment is isolation. Super bond is a new adhesive 
material which can be used successfully to stabilize the fragment even if the isolation is compromised. This article reports on the 
treatment of three coronal fractures at various levels by fiber post and a new adhesive material, Super bond.
Key words: Esthetic, Fracture reattachment, Super bond
Verma et al. Reattachment with super bond
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 88
After informed consent, a treatment plan for reattachment of tooth 
fragment was considered (Fig. 1).
As the patient had poor oral hygiene, oral prophylaxis 
was performed first. During treatment, after local anesthesia 
fractured fragment was removed and kept in the saline to 
prevent its dehydration. After access opening, working length 
checked with the help of apex locator (J Morita) and confirmed 
radiographically. The root canal was irrigated with 3% sodium 
hypochlorite (Septodont Novar pharmaceuticals) and prepared up 
to F2 with Protaper Universal (Dentsply Maillefer, Ballaigues, 
Switzerland). The root canal was dried using paper points and 
obturated using lateral condensation technique with Gutta-Percha 
(Dentsply Maillefer, Ballaigues, Switzerland) and AH plus sealer 
(Maillefer, Dentsply, Konstanz, Germany).
As the fractured margin was subgingival, the gingival flap 
raised for the attachment of fragment. After isolation, the fit 
of the fragment was checked. Green activator applied on both 
the segment and the tooth surface for 10 s. After rinse and dry, 
activated liquid was prepared and applied to the fragment and 
tooth surface, the fragment was placed in position and stabilized 
with finger pressure till the material sets. As it sets very fast, 
all these procedures were performed quickly. The flap was 
repositioned; sutured and post-operative instructions were given 
to the patients. The patient was regularly recalled and followed 
up to 6 months.
Case 2
A 24-year-old male reported to the department of conservative 
dentistry and endodontics, with the chief complaint of fractured 
lateral incisor due to motorbike accident 5 days ago. Intraoral 
examination showed Ellis Class III fracture in 22 and Ellis Class I 
fracture in 21. Careful examination revealed subgingival location 
of fractured margin. Radiographic examination showed additional 
horizontal incomplete fracture at the middle third of root.
After the examination, all treatment options were explained 
to the patient. As the patient was also willing to retain the tooth, 
reattachment of tooth fragment was planned. After informed 
consent, a single visit root canal treatment was performed. As 
additional root fracture was present in this case, intracanal post 
placement was necessary for stabilization of the fragment. Post 
space was prepared with #3 Peeso Reamer (LARGO, DENTSPLY 
Maillefer, USA) and an esthetic post (Angelus, Reforpost, 
Londrina, Brazil) of suitable size was placed to check its fit. 
Fragment stabilization was done in the same manner as in case 1. 
Follow-up was done up to 6 months (Fig. 2).
Case 3
A 22-year-old male patient reported with the chief complaint of 
fractured upper right posterior teeth due to sudden bite on hard 
object 2 weeks ago. After intraoral examination, the fractured 
mesiopalatal cusp of the right maxillary first molar involving 
root surface was encountered. Radiographic examination showed 
incomplete root canal obturation and the absence of coronal 
seal. All treatment options were explained after the examination 
and as the patient wants to save the tooth, the treatment plan for 
reattachment of tooth fragment was considered.
After obtaining informed consent, local anesthesia was 
administered; the fragment was removed and kept in the normal 
saline to prevent its dehydration. Endodontic treatment completed 
in a single visit and post placed similar to case 2. Fractured piece 
was attached after raising the flap as described in the earlier case. 
Rest of the tooth was restored with resin composite (3M ESPE, 
USA). Post-operative instructions were given. After removal of 
sutures and healing of gingiva, crown preparation was done and 
porcelain fused to metal crown was cemented to restore the tooth. 
Follow-up was done till 6 months (Fig. 3).
DISCUSSION
Maintenance of the mechanical, functional, and biological 
integrity is the essential factor in the management of traumatized 
teeth [7]. However, such treatment often presents a clinical 
challenge for the operator. In literature based on the location of 
fractured margin, various treatment modalities are available [6]. 
According to Olsburgh et al. [8] when there is invasion of 
biological width, treatment options are:
a. Removal of the fractured piece without any surgical procedure 
using composite resin at the gingival or subgingival level.
Figure 1: (a) Fractured maxillary right central incisor (b) after fragment (c) tooth fragment (d) pre-operative radiograph (e) post-operative 
(f) post-operative radiograph (g) 6 months follow up (h) follow up radiograph after 6 months
a
e
b
f
c
g
d
h
Verma et al. Reattachment with super bond
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 89
b. Gingivectomy with or without osteotomy that allows the 
reattachment of fragment in a single appointment. This 
procedure involves exposure of the cervical margin and proper 
isolation for reattachment of separated part. Osteotomy is 
performed if required. This is possible only when an excellent 
adaptation of the fractured fragment is present which allows 
keeping a minimum amount of composite on the margin.
c. Orthodontic extrusion: Disadvantage is the duration of treatment.
d. Immediate surgical extrusion is a more traumatic procedure. 
Endodontic treatment is sometimes necessary and there is a 
risk of external resorption.
The most widely used treatment method for the restoration 
of the traumatized tooth is the composite resin restoration 
which offers esthetic management although color instability 
and tendency to accumulate plaque makes it less preferable [9]. 
There is, however, no synthetic material that can replicate esthetic 
characteristic like natural tooth [10].
Restoration of broken tooth was also been attempted by full 
crown, but it is a more invasive procedure, and it also weakens 
the traumatized tooth by removing more of tooth structure. 
Hence, whenever the fragment of fractured tooth is available and 
biological width is not violated reattachment should be considered 
as the first choice [11]. Using a natural tooth to restore the 
traumatized tooth within a single appointment provides an esthetic, 
functional, and biological treatment. The flowable composite 
resin is the most commonly used material for reattachment of 
the fractured segment [7]. Although composite resin showed 
promising results in cases when fracture line is above gingival 
margin, the use of composite is not very easy when the fracture 
line is located subgingivally [12]. Maintenance of isolation is the 
greatest problem in such cases, and the composite material is not 
a biocompatible material for periodontal ligament adaptation [9].
During our literature search, we have found various procedures 
for reattaching fractured segment, but there are limited studies 
regarding the use of Super bond. In this case series, the material 
used for the reattachment is Super bond, self-curing dental adhesive 
cement. It contains 4-methacryloxyethyl trimellitate anhydride 
(4-META) as a diffusion promoter and tri-n-butylborane (TBB) 
as a polymerization initiator. 4-META is polymerized with methyl 
methacrylate (MMA) to form a copolymer and contributes to the 
excellent bonding property. TBB is tri-n-butylborane, an organic 
boron component presents in the catalyst. The catalyst reacts with 
oxygen in the air and water which are present on the tooth surface. 
The key to clinical success is that with TBB reaction proceeds 
in the presence of air and moisture. The 4-META/MMA-TBB 
resin is not affected by blood contamination, has a high tensile 
strength, and is biocompatible for periodontal ligament [13,14]. 
This material can be used successfully if the complete isolation is 
near impossible to achieve [15].
Figure 2: (a) Fractured maxillary left lateral incisor (b) after fragment removal (c) tooth fragment (d) pre-operative radiograph (e) post-
operative view (f) post-operative radiograph (g) 6 months follow up (h) follow up radiograph after 6 months
a
e
b
f
c
g
d
h
Figure 3: (a) Fractured mesiopatal cusps of right maxillary first molar (b) after fragment removal (c) tooth fragment (d) pre-operative 
radiograph (e) post-operative radiograph (f) post-operative view after crown placement (g) 6 months follow up (h) follow up radiograph after 
6 months
a
e
b
f
c
g
d
h
Verma et al. Reattachment with super bond
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 90
Table 2: Scoring criteria for all three cases
Clinical parameter Case 1 Case 2 Case 3
Anatomic form A A B
Color match A A B
Mobility A A A
Marginal adaptation A A A
Marginal discoloration A A A
Surface texture B B B
Patient satisfaction A A A
A: Alpha, B: Bravo, C: Charlie, D: Delta
All the cases were evaluated using the modified USPHS 
criteria listed in Table 1 [16]. In two cases, fiber post was also 
used to stabilize the fragment. Intraradicular stabilization of the 
fractured root using stainless steel or nickel-titanium files and 
metal or fiber posts has been reported in earlier literature also [17]. 
The patient was recently called for the 6 months follow-up. On 
each visit, tooth mobility, periodontal status, and radiographic 
examination were done. What can be more rewarding, if patients 
own natural teeth are retained, preventing him from psychological 
trauma of losing a natural tooth. All the three cases presented 
satisfactory result as evident from Table 2. The patient’s natural 
tooth anatomy, form function, and esthetics all were restored.
CONCLUSION
Due to the increasing incidence of trauma to dental tissues and 
their supporting tissues, it is important to know all the available 
techniques and available materials along with their pros and cons. 
With patients increasing esthetic demands, one of the best options 
to fulfill the requirements is to preserve teeth with reattachment 
treatments.
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Table 1: Modified USPHS criteria for clinical evaluation of the restorations and evaluation scores
Category Modified USPHS criteria for clinical evaluation of the restorations and evaluation scores
Alpha (A) Bravo (B) Charlie (C) Delta (D)
Anatomic form Restoration continuous with 
existing anatomical form and 
margins
Restoration is slightly over 
contoured or under contoured
Restoration is under 
contoured, dentin, or base 
exposed
Restoration is missing
Color match Restorations match the shade 
and translucency of adjacent 
tooth structure
Discoloration between 
restoration and tooth structure 
within the normal range of 
tooth
O’Boyle KH, Norling BK, 
Cagna DR, Phoenix RD. 
An investigation of 
new metal framework 
design for metal-ceramic 
restorations. J Prosthet Dent 
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normal range of tooth
Unacceptable 
color, shade, and 
translucency
Mobility Good bonding of fractured 
segment 
Fractured segment is partially 
retained with some portion of 
the restoration still intact
Fractured segment is mobile 
Marginal 
adaptation 
Resin-enamel interface is 
excellent; restoration closely 
adapted to the tooth
No crevice is visible at 
margins
Crevice at margin, enamel 
exposed
Restoration is mobile, 
fractured, or missing
Marginal 
discoloration 
No discoloration at margin Slight staining can be polished 
away
Obvious staining cannot be 
polished away
Gross staining
Surface texture Smooth surface Slightly rough or pitted Rough, cannot be refinished Surface deeply pitted, 
irregular groove
Patient satisfaction Fully satisfied Satisfied Unsatisfied Unsatisfied 
Verma et al. Reattachment with super bond
Vol 4 | Issue 2 | Mar - Apr 2018 Indian J Case Reports 91
biomechanical role of periodontal ligament in bonded and replanted vertically 
fractured teeth under cyclic biting forces. Int J Oral Sci 2015;7:125-30.
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17. Bains R, Tikku AP, Verma P, Chandra A, Yadav RK. Intra-radicular 
stabilization of a mid-root horizontal fracture. Asian J Oral Health Allied Sci 
2016;6:23.
Funding: None; Conflict of Interest: None Stated.
How to cite this article: Verma P, Bains R, Tikku AP, Singh M. 
Management of complicated crown fracture by reattachment with super 
bond: A case series. Indian J Case Reports. 2018;4(2):87-91.


Management of complicated crown fracture by reattachment with super bond: A case series

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Management of complicated crown fracture by reattachment with super bond: A case series

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